TEST 2 - UNIT B - EF - PRIORITY SETTING FRAMEWORKS

Question 1

Nurses should use clinical indicators such as

Answer 1

level of consciousness, trending of vital signs, skin color, pain level, and gastrointestinal changes to guide clinical decision making in determining a client’s clinical status.

Question 2

Although the ABCDE approach has traditionally been used in the acute care setting, it can be used in any

Answer 2

health care setting to assess and treat acutely ill clients.

Question 3

ABCDE framework places the highest priority o

Answer 3

n ensuring an adequate airway.

Question 4

Rationing of care can occur due to

Answer 4

inadequate resources, including time, staffing levels, and staff mix.

Question 5

Rationing of care means that

Answer 5

care is left undone, omitted, or missed due to limited resources.

Question 6

Missed care is considered

Answer 6

a medical error that can potentially affect client safety.

Question 7

Delegation of client care to other members of the interprofessional team is an option when

Answer 7

prioritizing client care, as it
gives the nurse more time to care for clients who have higher-acuity needs.

Question 8

A nurse may not delegate any task that requires either

Answer 8

nursing judgment or critical decision making.

Question 9

When implementing safety and risk reduction as a priority framework, nurses should choose to

Answer 9

intervene first in the situation that poses the greatest risk for injury to a client.

Question 10

When prioritizing care for a group of clients, nurses should

Answer 10

first rank the order in which clients should be seen, and then rank the order of care tasks for each individual client.

Question 11

To prioritize a group of clients in an ED, the nurse

Answer 11

first collects initial focused client data and assigns an acuity level to the client.

Question 12

Most EDs utilize a five-level acuity system that ranks clients who are

Answer 12

severely ill at level 1 and clients who are least ill at level 5.

Question 13

Nurses can assist with triage of groups of clients in the community following a mass-casualty event by using the

Answer 13

survival potential priority-setting framework.

Question 14

Mass-casualty triage differs from ED triage, in that

Answer 14

the most critically injured clients might receive no treatment if they have minimal chance of survival.

Question 15

ABCDE (airway, breathing, circulation, disability, exposure) approach

Answer 15

A systematic method that can be utilized in any health care setting to evaluate and treat the client. ABCDE is the acronym for airway, breathing, circulation, disability, and exposure.

Question 16

acute versus chronic

Answer 16

A framework in which acute conditions are prioritized over chronic conditions.

Question 17

direct care

Answer 17

Client care activities that are performed at the bedside.

Question 18

indirect care

Answer 18

Client care activities performed by the nurse away from the bedside.

Question 19

least restrictive/least invasive

Answer 19

Interventions are selected that maintain client safety while producing the least amount of restriction to the client;the nurse chooses interventions that are the least invasive.

Question 20

Maslow’s hierarchy of needs

Answer 20

A theory that suggests there are five categories of needs that motivate human beings. The five categories are psychological, safety, love and belonging, esteem, and self-actualization.

Question 21

nursing process

Answer 21

A framework that guides nurses in delivering client-focused care that takes the entire person into consideration. A five-step sequential process that guides nurses in assessing and prioritizing care for clients. The five steps are assessment, analysis, planning, implementation, and evaluation.

Question 22

rationing

Answer 22

Process in which allocated resources are scarce and there will not be enough to meet all of the required needs.

Question 23

resource allocation

Answer 23

The distribution of resources to a service or department.

Question 24

safety and risk reduction

Answer 24

Priority is given to whatever finding poses the greatest or immediate risk to the client’s physical or psychological well-being.

Question 25

survival potential

Answer 25

Priority is given to the client who has a reasonable chance of survival with immediate intervention. This framework is typically used in situations where resources are limited, such as with mass casualties and disaster triage.

Question 26

triage

Answer 26

To sort and rank treatment of clients according to the urgency of their need for care.

Question 27

unstable versus stable

Answer 27

Priority is given to the client who has an unstable condition versus the client with a stable condition.

Question 28

urgent versus nonurgent

Answer 28

Priority is given to the client who has an urgent need over a client with a nonurgent need.

Question 29

Hypertension is a chronic disorder; therefore, there is another client that the nurse should recommend as the priority for treatment.

Answer 29

DOES NOT REQUIRE EMERGENCY TREATMENT - BODY HAS HAD TIME TO ADAPT

Question 30

When using the acute vs chronic approach to client care, the nurse should recommend a client who reports new chest pain as the

Answer 30

priority for treatment. The client might be experiencing a myocardial infarction, which could result in poor outcomes if not identified and treated immediately.

Question 31

Arthritis is a chronic disorder and joint stiffness is an expected finding; therefore, there is another client that the nurse should recommend as the priority for treatment.

Answer 31

DOES NOT REQUIRE EMERGENCY TREATMENT - BODY HAS HAD TIME TO ADAPT

Question 32

Diabetes mellitus is a chronic disorder; therefore, there is another client that the nurse should recommend as the priority for treatment.

Answer 32

DOES NOT REQUIRE EMERGENCY TREATMENT - BODY HAS HAD TIME TO ADAPT

Question 33

A client who is scheduled for an abdominal ultrasound has a

Answer 33

nonurgent need; therefore, there is another client that the nurse should see first.

Question 34

A client who needs a urine specimen sent to the lab has a

Answer 34

non-urgent need; therefore, there is another client that the nurse should see first.

Question 35

When using the urgent vs. nonurgent approach to client care, the nurse should determine that they should first see a client who has

Answer 35

audible wheezing during respiration.

Question 36

AUDIBLE WHEEZING - PRIORITY BECAUSE

Answer 36

This client’s airway is partly compromised, and their condition could worsen quickly without urgent intervention.

Question 37

A client who is requesting their routine pain medication has a

Answer 37

non-urgent need; therefore, there is another client that the nurse should see first.

Question 38

The nurse might need to apply soft limb restraints to the client’s wrists to prevent the client from pulling the IV out; however, the nurse should

Answer 38

use a less restrictive intervention first.

Question 39

The nurse might need to administer a medication to sedate the client, such as an antianxiety medication, to prevent the client from pulling the IV out; however, the nurse

Answer 39

should use a less invasive intervention first.

Question 40

When using the least restrictive/least invasive priority setting framework, the nurse should use the

Answer 40

least restrictive or least invasive intervention before other more invasive or restrictive ones.

Question 41

An elastic bandage will

Answer 41

hide the IV from the client’s vision while at the same time allowing the nurse easy access to the site.

Question 42

The nurse might need to request a prescription for a central venous catheter; however, the nurse should

Answer 42

use a less invasive intervention first. Invasive procedures increase the risk of client harm.

Question 43

Invasive procedures increase the

Answer 43

risk of client harm.

Question 44

MASS CASUALTY SITE: A client who reports a possible sprained wrist and is walking around does not have

Answer 44

an immediate threat to life and can wait for treatment; therefore, there is another client the nurse should recommend for transport first.

Question 45

MASS CASUALTY SITE: A client who has an open forearm fracture without visible drainage does not

Answer 45

have an immediate threat to life and can wait for treatment; therefore, there is another client the nurse should recommend for transport first.

Question 46

MASS CASUALTY SITE: A client who has a respiratory rate of 6/min and no pupil response has a

Answer 46

minimal chance of survival even with intervention; therefore, there is another client the nurse should recommend for transport first.

Question 47

MASS CASUALTY SITE: A client who has an abdominal wound that is actively bleeding requires

Answer 47

immediate intervention for survival; therefore, when using the survival approach to client care, the nurse should recommend this client for first transport to a health care facility.

Question 48

A client who is hemorrhaging has

Answer 48

an immediate threat to life.

Question 49

Developing a nursing diagnosis, or analysis, is the _______ step of the nursing process.

Answer 49

second

Question 50

The first action the nurse should take when using the nursing process is to

Answer 50

assess the client.

Question 51

Assessment of the client includes a

Answer 51

physical examination, client interview, review of the medical records, and general observation.

Question 52

A registered nurse uses a

Answer 52

five-step sequential nursing process, which includes assessment, analysis, planning, implementation, and evaluation.

Question 53

Performing nursing interventions is the ____ step in the nursing process.

Answer 53

fourth

Question 54

Developing goals and outcomes is the ___ step in the nursing process.

Answer 54

third

Question 55

A client who is receiving a blood transfusion and reports urticaria is

Answer 55

unstable because this is a manifestation of anaphylaxis; therefore, the nurse should plan to see this client first. Anaphylaxis is a life-threatening condition that requires immediate attention.

Question 56

Anaphylaxis -

Answer 56

life-threatening condition that requires immediate attention.

Question 57

A client who has back pain and is requesting a muscle relaxant is

Answer 57

stable; therefore, there is another client that nurse should plan to see first.

Question 58

A client who has an ankle sprain and requests toileting assistance is prioritized

Answer 58

stable; therefore, there is another client that the nurse should plan to see first.

Question 59

A client who has chronic migraines and reports a headache is

Answer 59

stable; therefore, there is another client that the nurse should plan to see first.

Question 60

The nurse should recognize that love and belonging needs are motivated by the need for

Answer 60

social relationships. These needs come after safety and security needs.

Question 61

The nurse should recognize that self-actualization needs are motivated by the

Answer 61

need for self-fulfillment, or to reach one’s maximum potential and are only reached after all other needs have been met.

Question 62

The nurse should recognize that safety needs are motivated by the need for

Answer 62

security of the environment, personal security, and employment and must be met before addressing a client’s self-esteem needs.

Question 63

The nurse should recognize that self-esteem needs are motivated by the need to

Answer 63

feel good about one’s self and have the respect of others.

Question 64

If self-esteem needs are unfilled, the client may experience a feeling of

Answer 64

inferiority.

Question 65

This client reports a new onset of abdominal pain, which would be considered an

Answer 65

progress and worsen over an extended period.

Question 66

acute condition

Answer 66

, or a condition that appears suddenly and can worsen rapidly.

Question 67

The nurse should categorize NEW OSET OF ABDOMINAL PAIN AS ______________ if using the survival potential framework, rather than minimal.

Answer 67

DELAYED

Question 68

Clients who are tagged as minimal have a condition that can

Answer 68

wait hours to days for treatment. This client reports a new onset of abdominal pain, which requires investigation to determine the cause.

Question 69

Conditions in the urgent category

Answer 69

have a greater probability of poor outcomes if prompt actions are not taken.

Question 70

Abdominal pain can be caused by

Answer 70

non-life-threatening problems such as gas and constipation but can also be a manifestation of more significant illnesses such as bowel obstruction or appendicitis. The nurse should assess the client further to determine the cause of the abdominal pain.

Question 71

Clients who are tagged as expectant have a condition that is

Answer 71

likely to cause death despite treatment.

Question 72

Physiological needs are the

Answer 72

highest priority (Level 1).

Question 73

Physiological needs take priority over other needs because they are

Answer 73

essential for survival. The nurse should not address any other needs until physiological needs have been met.

Question 74

Safety needs are the

Answer 74

second level of priority in Maslow’s Hierarchy of Needs (Level 2). Once physiological needs have been met, the nurse should plan to meet safety needs.

Question 75

Love and belonging are the are the

Answer 75

third level of priority in Maslow’s Hierarchy of Needs (Level 3). After physiological and safety needs have been met, the nurse should address love and belonging.

Question 76

Esteem needs are the

Answer 76

fourth level of needs in Maslow’s Hierarchy of Needs (Level 4). The nurse should focus on esteem needs once the client has satisfied the need for love and belonging.

Question 77

Self-actualization is the

Answer 77

fifth level of needs in Maslow’s Hierarchy of Needs (Level 5). Only after all other needs have been satisfied will an individual be ready to turn their attention to self-actualization. The nurse should recognize that self-actualization is the lowest priority of need.

Question 78

Report of dizziness when standing indicates that

Answer 78

this client is at greatest risk for injury from a fall; therefore, this is the priority finding. The nurse should implement the nursing process to determine the cause of dizziness and implement fall precautions.

Question 79

Non pitting edema on lower extremtieis

Answer 79

This finding does not pose an immediate threat to the client’s physical or psychosocial well-being. The nurse should implement interventions to decrease the edema in the client’s lower extremities; however, another finding is the priority.

Question 80

scratch marks on abdomen

Answer 80

This finding does not pose an immediate threat to the client’s physical or psychosocial well-being. The nurse should collect subjective data from the client about the scratch marks on the client’s abdomen; however, another finding is the priority.

Question 81

When completing the exposure component of the ABCDE priority setting method, the nurse should observe

Answer 81

the client from head-to-toe for abnormalities. This includes the client’s lower extremities for indications of deep vein thrombosis such as pain, edema, and erythema of the calf area.

Question 82

When completing the exposure component of the ABCDE priority setting method, obtaining a respiratory rate is

Answer 82

ncorrect.

Question 83

The nurse should obtain a respiratory rate, including depth and pattern of respirations, when completing the _____________ of the ABCDE priority setting method. In addition, the nurse should also auscultate lung sounds, observe for chest wall symmetry during inspiration and expiration, and check for presence of retractions.

Answer 83

breathing component

Question 84

When completing the exposure component of the ABCDE priority setting method, the nurse should measure the client’s _________. An elevated _________ might indicate that the client has a current infection or other inflammatory process.

Answer 84

temperature
temperature

Question 85

The nurse should monitor the client for manifestations of bleeding such as bruising or abdominal distention in the

Answer 85

exposure component of the ABCDE priority setting method.

Question 86

The nurse should obtain a blood pressure measurement when completing the _______ component of the ABCDE priority setting method. In addition, the nurse should check pulse rate and quality.

Answer 86

circulation

Question 87

A client who received digoxin and has a heart rate of 48/min is

Answer 87

unstable; therefore, the nurse should identify this client as the priority for care. This heart rate is below the expected reference range. The nurse should report this finding to the provider and check for manifestations of decreased cardiac output.

Question 88

A client who is received pain medication and has a respiratory rate of 14/min is

Answer 88

stable; therefore, there is another client the nurse should identify as the priority for care. This respiratory rate is within the expected reference range.

Question 89

A client who has a urinary tract infection and temperature of 37.9° C (100.2° F) is

Answer 89

stable; therefore, there is another client the nurse identify as the priority for care. This temperature is within the expected reference range.

Question 90

A client who has anemia and a blood pressure of 118/78 mm Hg is

Answer 90

stable; therefore, there is another client the nurse should identify as the priority for care. This blood pressure is within the expected reference range.

Question 91

ABCDE approach - The nurse should assess the client’s body temperature as part of

Answer 91

step E (exposure); however, when following the ABCDE approach to client care, there is another assessment the nurse should perform first.

Question 92

ABCDE approach - The nurse should assess the client’s abdominal contour for

Answer 92

alterations, such as distention, as part of step E (exposure); however, when following the ABCDE approach to client care, there is another assessment the nurse should perform first.

Question 93

ABCDE approach - The nurse should assess the client’s skin integrity for

Answer 93

alterations such as the rashes, or lesions, as part of step E (exposure); however, when following the ABCDE approach to client care, there is another assessment the nurse should perform first.

Question 94

When using the ABCDE approach to client care, the nurse should determine to next assess the client’s

Answer 94

circulatory status after airway and breathing status.

Question 95

Indicators of circulatory function can include

Answer 95

taking a blood pressure, checking peripheral pulses, and measuring capillary refill time.

Question 96

The nurse should use the acute vs. chronic framework when trying to

Answer 96

determine if a client is experiencing a sudden condition change or manifestations of a long-term condition.

Question 97

The nurse should first care for clients experiencing _______ before caring for those experiencing _____

Answer 97

acute conditions
chronic conditions.

Question 98

Since this client is experiencing manifestations in multiple body systems, the nurse should use the

Answer 98

ABCDE framework to prioritize which assessment to perform first.

Question 99

The ABCDE method prioritizes the client’s

Answer 99

airway first,
followed by breathing,
circulation,
disability, and
exposure, so the first assessment the nurse should make is to ensure the client has an adequate airway.

Question 100

The nurse should use the _____ restrictive/ ______invasive priority setting framework when caring for clients who are posing a threat to themselves or others, or when deciding on invasive versus non-invasive nursing interventions.

Answer 100

least
least

Question 101

Before implementing restrictive or invasive measures, the nurse should attempt measures that are

Answer 101

least restrictive and least invasive but still maintain the safety of the client.

Question 102

The nurse should use the survival potential framework when caring for groups of clients involved in

Answer 102

mass casualty accidents such as natural disasters or acts of terrorism.

Question 103

The focus of the survival potential framework is to

Answer 103

provide the most good to the greatest number of clients with the resources available at the time.

Question 104

The nurse should inform the newly licensed nurses that the survival potential priority setting framework, used during

Answer 104

mass casualty situations,

Question 105

survival potential priority setting framework uses a color-coded system to

Answer 105

prioritize clients for treatment based on potential for survival. This priority framework seeks to provide the most good to the most clients with the resources available.

Question 106

The nurse should inform the newly licensed nurses that the least restrictive/least invasive priority setting framework gives priority to nursing actions that are the

Answer 106

least restrictive, or least invasive while still maintaining the safety of the client.

Question 107

The nurse should inform the newly licensed nurses that Maslow’s Hierarchy of Needs includes

Answer 107

client love and belonging needs, which can be met by encouraging social relationships and group interactions with personal friends and work connections.

Question 108

The nurse should inform the newly licensed nurses that the safety and risk reduction priority setting framework assigns the highest priority to the

Answer 108

factor or situation that will cause the greatest harm to the client’s physical well-being.

Question 109

Survival Potential Framework Assign aredtag to clients who

Answer 109

have life-threatening injuries but have a high chance of survival with immediate treatment (emergent; first priority for treatment).

Question 110

Survival Potential Framework Assign ayellow tag to clients who

Answer 110

have an urgent condition that could wait a short time for treatment (urgent; second priority for treatment).

Question 111

Survival Potential Framework Assign agreen tag to clients who

Answer 111

walking wounded, or clients who have injuries that are non-life threatening and could wait hours to days for treatment (nonurgent; third priority for treatment).

Question 112

Survival Potential Framework Assign ablack tag to clients who

Answer 112

deceased or have a minimal chance of survival despite treatment, and promote comfort for these clients (expectant; lowest priority).

Question 113

Criticalclient care needs require the nurse to

Answer 113

intervene immediately to prevent the client from deteriorating

Question 114

EX of critical care

Answer 114

(e.g., respiratory difficulty, chest pain, or a change in neurologic status).

Question 115

Urgentclient care needs are identified when the client could

Answer 115

suffer mild harm or discomfort if there is a delay in addressing the client’s needs

Question 116

Ex of urgent care

Answer 116

(e.g., postoperative pain).

Question 117

Routineclient care needs include tasks such as

Answer 117

administering routine medications and performing required shift tasks

Question 118

Ex of routing care

Answer 118

(e.g., routine vital signs, daily physical assessment).

Question 119

Extraclient care needs involve activities that are not

Answer 119

essential to client care but can promote client comfort

Question 120

Ex of extra care

Answer 120

(e.g., providing the client with a warm blanket, combing the client’s hair).

Question 121

BCDE (airway, breathing, circulation, disability, exposure) approach

Answer 121

A systematic method that can be utilized in any health care setting to evaluate and treat the client. ABCDE is the acronym for airway, breathing, circulation, disability, and exposure.

Question 122

acute versus chronic

Answer 122

A framework in which acute conditions are prioritized over chronic conditions.

Question 123

direct care

Answer 123

Client care activities that are performed at the bedside.

Question 124

indirect care

Answer 124

Client care activities performed by the nurse away from the bedside.

Question 125

least restrictive/least invasive

Answer 125

Interventions are selected that maintain client safety while producing the least amount of restriction to the client;the nurse chooses interventions that are the least invasive.

Question 126

Maslow’s hierarchy of needs

Answer 126

A theory that suggests there are five categories of needs that motivate human beings. The five categories are psychological, safety, love and belonging, esteem, and self-actualization.

Question 127

nursing process

Answer 127

A framework that guides nurses in delivering client-focused care that takes the entire person into consideration. A five-step sequential process that guides nurses in assessing and prioritizing care for clients. The five steps are assessment, analysis, planning, implementation, and evaluation.

Question 128

rationing

Answer 128

Process in which allocated resources are scarce and there will not be enough to meet all of the required needs.

Question 129

resource allocation

Answer 129

The distribution of resources to a service or department.

Question 130

safety and risk reduction

Answer 130

Priority is given to whatever finding poses the greatest or immediate risk to the client’s physical or psychological well-being.

Question 131

survival potential

Answer 131

Priority is given to the client who has a reasonable chance of survival with immediate intervention. This framework is typically used in situations where resources are limited, such as with mass casualties and disaster triage.

Question 132

triage

Answer 132

To sort and rank treatment of clients according to the urgency of their need for care.

Question 133

unstable versus stable

Answer 133

Priority is given to the client who has an unstable condition versus the client with a stable condition.

Question 134

urgent versus nonurgent

Answer 134

Priority is given to the client who has an urgent need over a client with a nonurgent need.